Provider Demographics
NPI:1487912705
Name:DIMINO, TABITHA GRANT (LMFT, MCAP, ICRC-ADA)
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:GRANT
Last Name:DIMINO
Suffix:
Gender:F
Credentials:LMFT, MCAP, ICRC-ADA
Other - Prefix:
Other - First Name:TABITHA
Other - Middle Name:LYNN
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1717 20TH ST STE 102
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-0619
Mailing Address - Country:US
Mailing Address - Phone:772-584-2501
Mailing Address - Fax:
Practice Address - Street 1:1717 20TH ST STE 102
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-0619
Practice Address - Country:US
Practice Address - Phone:772-584-2501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2022-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLADC-010451-2015101YA0400X
FLIMH10719101YM0800X
FLMT3149106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health